Introduction

Most people consider having a family to belong to and sharing mutual care essential for healing and adjusting to life after bereavement (Dyregrov & Dyregrov, 2008). These aspects may be especially significant for those bereaved by sudden, traumatic losses, like drug-related deaths (DRDs), which increase the risk for severe impairments in all health domains (Bottomley et al., 2021; Djelantik et al., 2020; Kalsås et al., 2022; Song et al., 2010; Spillane et al., 2017). Approximately 500,000 individuals die in DRDs every year (World Health Organization, 2022), impacting millions of bereaved people. Quantitative studies have shown that many DRD-bereaved people report severe grief reactions a long time after the death and achieve low scores in relation to social health dimensions (Bottomley et al., 2021; Kalsås et al., 2022; Titlestad & Dyregrov, 2022). Furthermore, qualitative works demonstrate that bereaved parents and family members struggle with a variety of stressors like complex relationships and stigmatization, complicated emotions like anger, shame, guilt, and relief, in addition to social isolation and finding communicating about the loss challenging (Lambert et al., 2021; Titlestad et al., 2021a).

The negative personal and relational impact of a traumatic death may also affect family functioning (Walsh & McGoldrick, 2013). However, the interpersonal and interactive factors in grief have so far been understudied (Delalibera et al., 2015; Stroebe et al., 2013b). Delalibera et al. (2015) reviewed the few publications on grief and family dynamics and concluded that troublesome interactions and low cohesiveness were associated with worse grief and psychosocial health. Following bereavement by suicide, social withdrawal between family members is frequently reported (Sajan et al., 2021), and studies have shown that family members` reciprocal efforts to protect each other from suffering have resulted in protective silence and non-communication between parents and siblings (Adams et al., 2019; Dyregrov & Dyregrov, 2005). In terms of couples, a longitudinal study by Stroebe et al. (2013a) showed that one partner’s withholding of emotional expressions to protect the other had the opposite effect of their intention, as suppressing their emotions was predictive of higher grief levels in their partner. In another longitudinal work, Buyukcan-Tetik et al. (2017) found that bereaved parents reported lower relationship satisfaction when one partner perceived that they had different levels of grief. Bergstraesser et al. (2015) explored how parents who had lost a child dealt with grief and identified that how they managed as a couple played an essential part. Coping with individual differences in emotions, perspectives, priorities, and actions were central themes, and open and continuous communication was crucial (Bergstraesser et al., 2015). Similar conclusions were drawn in a study by Dyregrov and Dyregrov (2017), who discovered that openly communicating thoughts and feelings was related to a couple’s satisfaction with their relationship after losing a child.

Regarding DRDs, an analysis by Titlestad et al. (2020) showed that communication strategies such as openness and talking with others were central themes in how parents adjusted to life after the loss, and O’Callaghan et al. (2022) generated similar themes in an exploration of 17 DRD-bereaved family members focusing on posttraumatic growth. Still, complex familial relationships and challenges in communication about the loss, both within family relationships and between the family members and extended social networks, remain recurring themes in publications on this population (Dyregrov et al., 2022; Lambert et al., 2021; Titlestad et al., 2021b).

Family Resilience and the Dual Process Model of Coping with Bereavement

For this study, we define family as the people living together in a shared household, with an extended circle connected through biological/formal family ties, including those who have lived with biological family members in a relatively stable relationship over time (Koerner & Fitzpatrick, 2012). Walsh (2021) suggests that resilience in families should be assessed in terms of how they approach adverse situations, their immediate response to the situation, and their long-term coping strategies. Hooghe and Neimeyer (2012) emphasize three processes for strengthening family resilience in the wake of loss: (1) family meaning-making, emphasizing shared participation in conversations where both positive and negative feelings can be shared and meaningful shared rituals can take place, (2) open communication or emotional sharing to forge stronger bonds and increase relational intimacy, and (3) fostering relational connectedness and family cohesion.

In addition to the relational, communicational/emotional and meaning-making processes, Walsh and McGoldrick (2013) also emphasize the possible need to reorganize the family system by realigning relationships and redistributing role functions. Olson et al. (2019) use the term family flexibility to define the quality and expression of leadership and organization, as well as role relationships, relationship rules, and negotiations in the family. Family flexibility addresses questions such as who makes decisions, who is responsible for what tasks, and how these responsibilities and decisions are negotiated, expressed and executed. Addressing such topics can ensure that changed responsibilities in the family are distributed in ways that are adequately balanced with individual capacities, the needs of different family members, and the family unit.

Stroebe and Schut (2015) have developed a revised version of the Dual Process Model of Coping with Bereavement that integrates grief processing on a family level (DPM-R). A central loss-oriented family task includes how sharing emotions may reduce the family members’ grief and increase family cohesion (Stroebe & Schut, 2015). Restoration-oriented tasks include how the family takes part in shared non-grief-related activities and how they manage to move on with new roles in the family. Stroebe and Schut (2015) assert that family-level stressors such as conflicts or poverty may challenge their acceptance of the changed world. For many DRD-bereaved families, such challenges will probably also include the cultural stigma associated with drug use and drug users (Dyregrov & Selseng, 2021; Titlestad et al., 2021b).

The reviewed studies consistently show that communication on the interpersonal level through sharing and openness is essential for individuals and relationships when grieving a loss. These findings are supported by family resilience theory (see Hooghe and Neimeyer, 2012; Walsh and McGoldrick, 2013) and the DPM-R (see Stroebe and Schut, 2015). However, studies also demonstrate that such interactional processes may become complicated or blocked. Families affected by problematic drug use are often severely strained, and the members frequently struggle with complex emotions, relations and loneliness (Di Sarno et al., 2021; Lindeman et al., 2021). Those bereaved by DRDs often report complicated relationships and social isolation (Dyregrov et al., 2022; Kalsås et al., 2022; Titlestad et al., 2021b). Thus, they face the double risk of a traumatic bereavement combined with difficulties connecting, communicating and receiving support in their family. To our knowledge, no existing studies focus primarily on DRD-bereaved people’s interaction and help needs on a family level. Hence, this analysis aims to generate knowledge regarding those help needs based on DRD-bereaved parents’ reflections on family interactions.

Method

This study is part of the Norwegian END-project that started in 2017. The project focuses on DRD-bereaved people’s psychosocial situation, their help needs, the help and support provided, and health and welfare services’ way of relating to them.

Recruitment and Sample

Between March and December 2018, 255 DRD-bereaved family members and close friends/partners from across Norway were asked to complete a survey. Of these, 95 were parents, 75 agreed to be contacted for individual interviews, and 14 were interviewed. Inclusion criteria were that participants spoke fluent Norwegian and that the death had happened at least three months before recruitment. The parents were recruited based on the following variables in order of priority: gender, place of residence (including northern/southern/western/eastern parts of the country and urban/rural areas), a variety of ages above 18 years, a range of durations since the death occurred, and parents of deceased children of both genders and various age. Table 1 presents background data of the participants.

Table 1 Characteristics of participants (N=14)
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All parents reported that the deaths had happened suddenly. One mother had lost two of her children to DRDs, and two parents in the sample had lost the same child but had been divorced for several years before the death. In two cases, the other parent was dead, and in 10 cases, the interviewed parent was no longer a partner to the other parent. In these 10 cases, the break-up occurred before their child’s death. At the time of the interviews, 12 parents had grown-up children. Seven parents had grandchildren; in five cases, some or all of these were the children of the deceased. Most of the grandchildren were under the age of 18 years, and only two children of the deceased were adults at the time of the interviews.

Semi-Structured Individual Interviews

The interviews were conducted by three researchers in the END-project between August and December 2018 (clinical social educator Kristine Berg Titlestad, sociologist Kari Dyregrov, and psychologist Sonja Mellingen). The semi-structured interviews followed a guide with five overarching topics based on theory and previous research on traumatically bereaved populations: (1) time before the death, (2) the period after the death and the grief process, (3) stigma and self-stigma, (4) experiences of support and help, and (5) coping and posttraumatic growth. The interview guide was calibrated through a pilot interview with a DRD-bereaved parent conducted by the team’s senior grief researcher (K.D.) with all other interviewers present, followed by a discussion with the interviewee and the interviewers.

The interviews took place in private settings selected by the participants. Nine interviews were conducted at the participant’s home, four at their work office, and one in a hotel. The form of the interviews was fairly open, first and foremost following the interviewee after the initial question asking who the deceased was and the nature of the interviewee’s relationship with them. However, all the interviews included the topics mentioned above. The interviews lasted from 1.5 to three hours, including breaks. The interviews were audio-recorded and transcribed verbatim by a research assistant. Transcripts covered 431 single-spaced pages; each interview ranged from 20 to 39 pages. When half of the interviews had been conducted, the interviewers exchanged experiences and calibrated future interviews based on notes and experiences.

For sample selection and size, we drew on Malterud et al. (2016) proposals of criteria for determining information power, which depends on the study aim, sample specificity, use of established theory, quality of dialogue and analysis strategy. The study aims for the interviews were broad, encompassing all the aims of the END-project. Thus, only a limited part of the interview data was related to the current study. The sample specificity was high, as the parents belonged to the target group and had considerable variations in experiences. The study did not rely on a solid theoretical background, suggesting a need for a larger sample to obtain sufficient information power. We perceived the quality of the dialogues of the interviews as ranging from medium to very high. Finally, the in-depth and primarily experiential-hermeneutical analysis strategy in a reflexive thematic framework requires fewer participants than, for example, a cross-case analysis. After assessing the need for further interviews after 13 were conducted, one last interview was conducted to even the gender distribution in the sample. This final interview contributed only marginally to new knowledge; thus, we decided satisfactory information power was obtained.

Individual interviews were preferred over relational interviews because of their purpose and feasibility. Most topics covered in the interviews were of a personal character, which we found to be best approached in an individual setting. The process of reaching a sample with diverse individual demographic characteristics was demanding, and we prioritized individual over relational diversity (e.g., parents of the deceased that still lived together, relationship between split-up parents that would allow joint interviews etc.). Furthermore, interviews with parents were chosen instead of, for example, siblings, as parents often are in an empowered position vis-à-vis help services due to their position in families and the “grief hierarchy” (cf. Robson and Walter, 2013). In addition, parents often take the initiative for other family members, especially adolescents, to access help services (see Andriessen et al., 2019; Rickwood et al., 2015). Thus, the parents` experiences and views are of special importance when assessing whether family-oriented help efforts might be needed and feasible.

Analysis

The analysis followed the guidelines for reflexive thematic analysis (Braun & Clarke, 2022). An experiential-hermeneutical approach guided the analysis, in which we aimed to understand the help needs of the parents based on an intimate understanding of how they experienced the phenomena of family interactions (Braun & Clarke, 2022). The first, second, and last author read all the interviews. The first author conducted all the coding, shared the codebook with the other authors, and adjusted the codes and themes based on discussions between the researchers.

The research question addressed how the need for family-oriented help could be understood through DRD-bereaved parents’ reflections on family interactions. The analysis was inductive, explorative, and developed from a semantic interpretation to a more latent one as the wholeness of the data and codes provided more context for the data segments (see Braun & Clarke, 2022). Hence, the final codes’ analytic approach is in the middle of the semantic and latent coding range. All the interviews were read in the familiarization phase (Phase 1), with any reflections and questions noted. In the second reading, highly relevant passages that dealt with family life and interactions were highlighted but not coded. Phase 2, involving coding, was conducted through a close third reading of the interviews, emphasizing the previously highlighted segments. The process and evolvement of the codes and labels were carried out by thoroughly undertaking the coding process twice, followed by a light rereading of the code labels and segments and a discussion with the co-authors. The recursive process involved moving back and forth when developing the themes in phases 3-5. Finally, we arrived at three themes that included 50 codes. These were then checked against the suggested theme evaluation questions outlined in Braun and Clarke (2022). All coding was undertaken by the first author using NVivo 1.6. The theme development encompassed both manual labor with paper and the NVivo software.

Ethical Considerations

The Norwegian Regional Committee for Medical and Health Research Ethics has approved the END research project (ref. nr. 2017/2486/REK vest). All participants received written information about the project’s aim before participation and were verbally informed about the study’s purpose and methodology at the start of the interviews. Furthermore, it was explained that the data would be stored on the research server at the university and published in a non-identifiable form. The parents provided written consent for participation and were informed that they could withdraw from the process at any time and demand the deletion of their data. The inclusion limit of three months since loss and the interview procedures followed experiences from co-author and project leader K.D.`s comprehensive research on traumatically bereaved populations (see Dyregrov, 2004; Dyregrov and Dyregrov, 2008). The participants were given information, including the project leader`s phone number and e-mail address, and invited to make contact after the interviews if they needed follow-up. All the parents reported positive experiences related to their participation.

All the interview citations have been anonymized by changing any recognizable elements, including given names. In addition, verbose oral speech and fillers irrelevant to the current themes have been removed from the quotes, taking care not to undermine the authenticity.

Trustworthiness

Lincoln and Guba (1985) propose that credibility, transferability, dependability, and confirmability indicate the trustworthiness of qualitative research. Measures to achieve adequate credibility were the first author’s writing of a self-reflexivity note on both personal, functional and disciplinary reflexivity (see Braun and Clarke, 2022; Wilkinson, 1988) in advance of reading the interviews, increasing the awareness of own prejudgments before analyzing the data. Furthermore, the process of reflexivity was ongoing throughout the analysis by continuously writing a reflexive journal, ongoing discussions on analytic choices and coding with the last author (K.B.T.) and two joint discussions with all authors.

The authors have various disciplinary backgrounds that were drawn upon to ensure a breadth of perspectives in discussions: Ø.R.K. and S.K.L. are social workers and family therapists with twenty years of experience within substance use treatment and rehabilitation, L.T.F. is an MD, clinical specialist in family medicine who also has lead research projects in substance use and health, K.D. is a sociologist highly specialized in grief research, and and K.B.T. is a social educator with a PhD on parents` grief after a drug-related death. To illustrate reflexivity, all codes and coded data segments were revised after the first joint meeting, as they did not adequately capture the relational aspects the research question aimed to capture. Furthermore, the development of themes also resulted in discarding the initially developed themes, as Ø.R.K. and K.B.T. evaluated them as too deductively oriented. Another feature of credibility, prolonged engagement (cf. Lincoln and Guba, 1985), was ensured through media appearances by the project leader and project group members and a countrywide conference where members of the study population were invited free of charge. These events early in the research project were crucial for building trust in the study population.

Dependability is heightened by an audit trail that has described all research steps. Confirmability was achieved through the discussions and reflection with the other researchers who had read all the interviews (K.B.T. and K.D.), and transferability was achieved through the thick descriptions with context information.

Data Availability Statement

The interview data that support the findings of this study are protected and not available due to ethical obligations and data privacy laws.

Results

We generated three themes as a result of our analysis of the parents’ reflections (Table 2):

  1. I.

    Considerable needs in the family become our responsibility.

  2. II.

    Conversations that are important for family connections are obstructed.

  3. III.

    As parents, we can strengthen family connections.

Table 2 The research question, theme titles, and theme descriptions
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I. Considerable Needs in the Family Become Our Responsibility

This theme captures the parents’ expressions concerning the challenges the family and family members faced after the loss and how the parents often took responsibility for attending to different family members’ needs. These challenges were often stated when discussing the needs of children in the family, mainly the parents` grandchildren or the sibling(s) of the deceased.

Many parents expressed a need for adjustment in the family structure to ensure adequate care for children, taking great responsibility for such needs, sometimes even becoming their parentally bereaved grandchildren’s foster parent. Some parents experienced overwhelming tasks, like this mother who cared for three parentally bereaved grandchildren:

(…) and then I was a mom for three more with completely different needs. And (…) they had a complicated relationship with their mom, and the boy to the father. He has not seen his father in many years, and it is a process that is always difficult. And then (sigh), I felt I had octopus arms with hands in all directions. And then I was supposed to satisfy all kinds of things, and I was quite overstretched. Both physically and mentally. (Emma, lost daughter).

Many parents clearly stated the needs of different family members and the family unit. In addition to the deceased person’s children, the deceased’s siblings were highly prioritized in many parents’ care focus. The parents recognized that many siblings faced struggles connected to the loss, and although they tried to reach the siblings in various ways, the task was often difficult. Still, the parents shared hardly any examples of family-oriented professional help that aided connections within the family. For example, Clare had a daughter with substance use problems who also struggled with grief after her brother’s death. Clare continuously tried to enter a dialogue with her daughter regarding her struggles but did not feel she could reach her. She stated that she had missed that some professional service had involved them both in conversations: “(…) because I think that if it comes from me (…) it is more resistance in her than if someone had contacted us and said that they can offer conversations for each of us, and one joint conversation, or something like that”.

Some parents noted that other family members did not receive help from health and social services in their own right either, illustrated with Reese’s experiences with her general practitioner:

No, he is concerned with me, yes, he is. But no one else, so my husband (the step-father) has no one, really. (…). Marion (the child of the deceased) has no one either, it’s just me, and we talk, but not so often, because her grief is something completely different. (Reese, lost son).

The health and social services’ lack of focus on the family system and other family members left the parents responsible for trying to meet their family members’ needs. Several parents seemed very used to taking such responsibility through a role as one who watches out and cares for others. For some parents, a tendency to protect other family members from their own grief seemed to accompany this role. This phenomenon was sometimes expressed in a somewhat contradictory way, where parents missed support in the family but also were afraid to enter a situation where others might feel that they had to care for them:

I actually miss someone who can meet me and let me unload, but I haven’t got that, my husband cannot do that. Right, he would not have known what to do with it (…), and if I had collapsed in his arms, I think he would have become terrified as a matter of fact, and I cannot do that to him. (Reese, lost son).

Overall, many parents considered the family’s and family members’ needs to be comprehensive, and several took great responsibility for fulfilling those needs. Few had received integrated help for the family, which increased the workload on the parents. In addition, several parents seemed to assume the role of one who should care for others, protecting other family members from their own grief and needs.

II. Conversations that are Important for Family Connections are Obstructed

This theme captures how interactional processes that might be essential for maintaining or deepening connections within the family were obstructed by difficulties in talking about the loss, grief, and deceased’s life with family members. Approximately half of the parents reflected on how conversations regarding their child and ensuing grief were impeded. Several parents said family members avoided the topic and sometimes failed to respond when they expressed feelings of grief or talked about the deceased. In a few cases, they could not talk about the death and the hard feelings at all:

And I think many of them, my siblings and sisters in law and others I know, and my mother doesn’t talk, she doesn’t ask anything. (…) I must say that I have missed it, of course it is hard to talk about, but at the same time, when people actually do not comment that you have lost a son or a situation like this, don’t comment it at all, that also becomes very strange. (Vera, lost son).

Fear of grief and “hard feelings” were most frequently mentioned as possible reasons why the parents did not find space to talk about the loss with family members, as well as difficulties in finding the words to talk about it together.

Some parents felt left in the dark concerning other family members’ stances, so they assumed their intentions and reasons without them being voiced. Many assumptions about the family members’ reasons for avoiding the topic were positively connotated, like wanting to protect the parent from hard feelings. In addition to assuming protection as the rationale for family members’ avoidance of bringing up the person who died and the grief, some parents also noted that they used the same reasoning for avoiding the topic themselves.

Sometimes, bitterness and blame were represented as dangerous elements in conversations and family connections. In most cases, this was somewhat vaguely mentioned as an underlying fear inhibiting conversations, but there were also cases where this was explicitly noted. For example, one father said that his ex-wife’s blaming of him was the triggering cause for their failure to talk to each other about their remaining child after the death: “(…) You understand why, when the mother started a meeting by stating that I am one out of two people who have killed our son (…)”. (Christian, lost son).

Many parents also talked about family members who struggled with their own grief and/or psychosocial difficulties. Sometimes, the parents had been unaware of these struggles, and at other times they felt powerless to help their family member. The former was especially linked to the role of step-parents, where some parents were not aware of how they struggled although they had been deeply integrated with the family for a long time: “Then I just see that the tears (of my partner) flow, I sat here, and he sat here: ‘I am not fucking allowed even to grieve’”. (Emma, lost daughter). The feeling of powerlessness in helping other family members was especially stated concerning the deceased’s children and siblings. The parents expressed awareness of their struggles but did not manage to reach them: “She (step-daughter) sits with a feeling of guilt in one way or another. I’ve said that you must not do that, but it sits deep in her, so she struggles really hard”. (Patrick, lost daughter).

Overall, the parents talked about how obstructions to important conversations about the deceased, the loss, and the bereavement were assumed to be rooted in a fear of eliciting grief reactions and hard feelings like bitterness and blame. Several parents discussed how they avoided speaking about their grief and showing their vulnerability to other family members. Finally, some parents shared experiences of problems in reaching those family members who struggled after the death, and sometimes a lack of awareness of these struggles.

III. As Parents, We Can Strengthen Family Connections

The last theme expresses how parents try to navigate family life to maintain or deepen family connections, often successfully. Experiences of togetherness as family members and growing closer as a family, as well as bonds with grandchildren, all had major contributions to the parents’ experiences of purpose and their quality of life. Several parents highlighted the importance of creating space to talk and listen to each other, and create open dialogue about the situation and the loss, like Ralph who had lost his son: “I think, no matter what, I do mean it is important to talk about it, the worst you can do is not talk about it. No matter what”.

Some parents shared experiences of family members expressing an ambivalent or strained relationship with the deceased, such as shamefulness regarding their drug use and lifestyle. As family members consequently had vastly different grief reactions, creating space to talk and listen was associated with acknowledging such differences in feelings about and relations to the deceased.

Some parents described a somewhat fragmented family structure. Most parents were divorced from the other parent of the deceased. In the cases where the deceased had children of their own, the deceased son or daughter was most often not committed to the main care of those children before their death. Sometimes the parents assumed the role of foster parents temporarily or permanently, which challenged the family structure and cohesion. In another case, the parent did not know she had a grandchild until after her own child’s death. Still, many parents managed to navigate these structural challenges and create or maintain good connections.

Several parents also described how they tried to navigate the threat of blame distribution in the family, trying to keep it from creating conflicts or distance from each other. This motivation was clearly stated by Jeremy, reflecting on the communication with family members and relating it to the son`s diary notes:

(…) You could very well enter a state of bitterness, it is clear that there were a whole lot of questions and critical questions at times. (…) I am actually the only one who has read these (diary notes). I have just told them that I have them, and you can read them if you want, no problem. But the catch is that suddenly you might start with some distribution of blame, and then it is a bit like… I say that nothing good comes from it. (Jeremy, lost son).

In addition to reflecting on different ways of adjusting interaction in the family to navigate dilemmas and threats to the family connections, approximately half of the parents had experiences of not needing much help from other sources when they felt that relations in the family and social network functioned well. Margaret, who lost her son, illustrated this experience when describing her relationship with her grown-up children and their families: “(…) we really are quite close, so we haven`t needed so much else than that.”.

Overall, the parents reflected on their efforts to maintain and strengthen family connections by creating space to talk and listen to each other and being open in family communication. Some parents also talked about how they navigated challenges like blame and bitterness in family interactions by being conscious of how they talked about the loss and the grief within the family. Finally, approximately half of the parents interviewed experienced a low need for outside help from health and social services when they perceived family relations as safe and supportive.

Discussion

The generated themes, (I) Considerable needs in the family become our responsibility, (II) Conversations that are important for family connections are obstructed, and (III) As parents, we can strengthen family connections, reflect both barriers to family connection and flexibility and the agency of the DRD-bereaved parents in positively impacting the family environment.

Theme I, Considerable needs in the family become our responsibility, is a finding that seldom is reported in other studies on traumatically bereaved parents, although role changes within the family often are a consequence when losing a family member (see Walsh and McGoldrick, 2013). The finding might be related to the time before death, as many parents had lived with problematic drug use in the family for years. Experiences of overwhelming stress and responsibilities have been reported in many studies on parents affected by substance use (cf. Di Sarno et al., 2021; Lindeman et al., 2023; Lindeman et al., 2021; Orford, 2017; Titlestad et al., 2021b). Furthermore, many parents in the current sample have previously reported being in constant preparedness for a long time before the death, “prepared to step in if their child needed help, while putting their own life on hold” (Titlestad et al., 2021b, p. 5). Similar experiences have been described in a metaetnography comprising several studies on substance use and family life, reporting that parents often “expressed guilt caused by a sense of never-ending responsibility for the adult child” (Lindeman et al., 2021, p. 8). Concerning other family members, a study focusing on DRD-bereaved siblings’ experiences before the loss, reported that the siblings often tried to balance the family environment and functioning by not taking significant space in the family (Løberg et al., 2022). Thus, the pre-loss stress imposed on the family members and the consequent family adjustments probably affect the family flexibility and parents’ experienced responsibilities also after death. The post-loss needs within the family might underscore these responsibilities even further.

Theme II, Conversations that are important for family connections are obstructed, resonates with findings from a recent study on DRD-bereaved siblings, who reported that the siblings often relied on themselves post-loss, not sharing difficult emotions and experiences with family members due to challenging family relations (Dyregrov et al., 2022). The theme also echoes findings from studies on bereavement by suicide, where obstructions to family conversations concerning the loss are frequently reported (see Sajan et al., 2021). For example, Chapple et al. (2015) discussed how sharing emotions concerning self-inflicted deaths seems especially challenging. Furthermore, parents in the current study described mutual avoidance of conversations on loss-oriented topics to protect the other family member from pain, which resonate with findings of protective silence reported in many studies on suicidal deaths (Adams et al., 2019; Sajan et al., 2021).

Still, “why”-questions are especially stated after deaths where the deceased are perceived to bear responsibility for the death (see Dransart, 2013; Pritchard & Buckle, 2018), including DRDs (cf. Titlestad et al., 2020, 2021a). Such questions prompt meaning-making processes, which are highly interpersonal (Neimeyer et al., 2014), and make social sharing especially important after these kinds of bereavements. The absence of emotionally oriented conversations is most likely a driver for social withdrawal (see Rimé, 2009; Rimé et al., 2020), frequently reported after both suicidal deaths (Azorina et al., 2019; Sajan et al., 2021) and DRDs (Kalsås et al., 2022). Thus, the theme Conversations that are important for family connections are obstructed, has important implications for the DRD-bereaved families` potential help needs.

Theme III, As parents, we can strengthen family connections, align with studies concerning social processes that people in bereaved families find helpful. The theme includes creating space to talk and listen to eachother, being open in communication, and navigating relational and emotional challenges while maintaining relationships. Openly communicating emotions and feelings regarding the loss and the deceased, as well as own needs, are rated as an important self-help strategy for many bereaved people (Dyregrov, 2004). This way of communicating is also consistently associated with better individual and relational adjustment to loss (see Bergstraesser et al., 2015; Dyregrov and Dyregrov, 2017; Stroebe et al., 2013a). Thus, this theme captures the parents’ agency in impacting their own psychosocial situation and the family cohesion after the death.

Clinical Implications

Based on these findings, we suggest approaching the family-oriented help needs of such families through two main frameworks (Table 2). The first is the Dual Process Model of Coping with Bereavement - Revised (DPM-R), which includes family-level coping (Stroebe & Schut, 2015). The other framework is based on family resilience, understood as the family’s capacity, as a functional system, to withstand and rebound from disruptive life challenges (Walsh, 2021, p. 256). In this section, we use the term “family-oriented help” denoting help from professionals formally trained in facilitating multi-actor dialogues and understanding family interaction and structure. Family-oriented help could, for example, be provided by professionals trained in systemic family therapy (Wampler et al., 2020) or Open Dialogue (Seikkula, 2005).

Fig. 1
figure 1

The family-level processes following DRD and potential help needs

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The model suggests two paths for assessing and approaching family-oriented help needs based on theory and findings in this study. The white boxes are derived from theory based on the DPM-R (see Stroebe and Schut, 2015) and family resilience (see Hooghe and Neimeyer, 2012; Olson et al., 2019; Walsh and McGoldrick, 2013). The row of dark gray boxes are the themes from the current study.

The theme “Considerable needs in the family become our responsibility” denotes processes that might indicate or lead to “Unbalanced family flexibility”. In parallel, “Conversations that are important for family connections are obstructed” denotes processes that might indicate or lead to “Decreased family connections”. “As parents, we can strengthen family connections” denotes the bereaved parents` efforts to strengthen family connections and flexibility. The double arrows between the outcomes of family flexibility and family connections, illustrate the likely interaction between these processes. Finally, “In need of family-oriented help” follows from “Unbalanced family flexibility” and “Decreased family connections”, illustrating that the family might need family-oriented help if they struggle in one or both of these domains.

Restoration-Oriented Tasks: Assessing Family Needs and Renegotiating Family Interactions and Roles

The right path of the model concerns matters of family structure, roles, and flexibility; matters vital for moving on as a family after the loss, i.e. restoration-oriented tasks (see Stroebe and Schut, 2015). The DRD has disrupted the family system, and the considerable needs of the family and family members must be met. If the adjustments to balance the individual family members’ needs and caretaking capacities are made appropriately, balanced family flexibility will probably be achieved (see Olson et al., 2019; Walsh and McGoldrick, 2013). The considerable needs within the family and the parents` experienced responsibility can be a barrier to adequate adjustment.

Our findings indicate some central questions in making such adjustments: who should have daily care of the children of the deceased? Who should provide adequate support to the ones who take on these responsibilities? How can the remaining sibling(s) get the support they need? Should I be the one to whom others in the family come with their needs, or is there more room for reciprocity? What are the barriers to reciprocity and how could we find a balance in our family? To whom can I turn to with my grief and need to share emotions and experiences? Could I show (more) vulnerability to any of my family members, and might that possibly open up new ways of being together in the family? How can we facilitate safe spaces for such sharing? How much should the children be shielded or “see” my grief, and how should I approach and support their grief?

Loss-Oriented Tasks: Socially Sharing Emotions Related to the Loss

The social sharing of emotions between family members following a loss is a vital part of meaning-making and can help maintain or increase family connection and cohesion (see Hooghe and Neimeyer, 2012; Rimé et al., 2020). Based on our findings, obstructions to social sharing seemed linked with family members’ fear of raising hard emotions, their insecurity in expressing them, and how to deal with them. When family members experienced these obstructions to emotional sharing, some families seemed unable to create the space to talk and listen to each other.

Family-oriented help efforts could aid family members in addressing necessary topics and endure, relate, and respond to the emotional expressions that arise when doing so (see Seikkula and Trimble, 2005). When helping with the social sharing of emotions and meaning-making processes, therapists should be reflective on the family members` different need to share and their ability to listen (Hooghe et al., 2018), and accommodate for different family environments and cultural norms (cf. Li et al., 2023). If conducted competently, facilitating such processes could widen the family members’ tolerance of complex emotions and increase connectedness between family members, increasing the family members` ability to address and explore such topics without professionals at a later stage.

Taken together, we suggest that family-oriented help might aid DRD-bereaved families in addressing family flexibility (restoration-oriented task) or the social sharing of emotions (loss-oriented task) if they struggle to do so independently. Furthermore, we suggest that such help is provided within a family resilience framework, viewing family members as “valued partners and essential in addressing their problems” (Walsh, 2016, p. 136) and advocating a non-pathologizing perspective with corresponding demands for non-stigmatizing language (Walsh, 2016). A family resilience framework can challenge the implicit or explicit notion that there is something “wrong” with the family when suggesting family-oriented help interventions (see Haley, 1997; Walsh, 2016). Given the already present threats of stigma, guilt/blame, and shame in many DRD-bereaved families (Titlestad et al., 2021a, b), such sensitivity may be crucial.

Limitations and Future Directions

Strengths of this study include a purposefully recruited heterogeneous sample of DRD-bereaved parents who were interviewed in safe settings with an interview structure co-designed with a participant from the target population. However, some limitations must be considered. The interviews explored several aspects of the parents` experiences in addition to family-oriented topics, as the knowledge of experiences with drug-related bereavement has been very scarce. Interviews focusing solely on family themes would have provided richer data for answering our research question. The research question has only been answered by interpreting the parents’ reflections. Including other family members would have generated more nuanced and possibly different answers (cf. Dyregrov et al., 2022).

We did not have the opportunity to include the participants in the analysis and writing of the report through member checking, which would have enhanced the study`s trustworthiness. It should also be noted that most parents were divorced from the other parent. Some parents expressed a close relationship, while others noted a conflictual relationship with their ex-partner. Thus, the divorce`s impact on the information shared in the interviews is probably multidirectional. Finally, although the sample was heterogeneous in some aspects, it was homogeneous regarding ethnicity, sexual orientation and the parents’ household income and education, which were somewhat above the Norwegian norm. This homogeneity means that the transferability of the findings has limitations.

As both this and a previous study from Norway show that family-oriented help is scarcely available for this population (Kalsås et al., 2023), we recommend that future investigations focus on family-oriented needs and help interventions. Such works could include the feasibility of screening for family functioning and coping in bereaved families, for example, using the circumplex model (Olson et al., 2019) or the Walsh Family Resilience Questionnaire (Duncan et al., 2021). Furthermore, analyses of help interventions at the dyadic, parental, or family levels are lacking for all bereaved populations (Baumann et al., 2022; Dias et al., 2019). Considering the complex ethical and practical domain of bereavement, families, and help-providing, a variant of a participatory action research design could be the most ethically sound and flexible method for developing family-oriented therapeutic help practices that meet the population’s needs.

Conclusion

The current study has identified processes showing DRD-bereaved parents` agency in strengthening family connections and barriers to family connections and flexibility in the bereaved families. The barriers were related to the parents` experiences of (a) responsibility for highly demanding needs in the family and (b) obstructions to loss-oriented conversations where emotions are shared. We have argued that these barriers might relate to the impact of problematic drug use on the family unit before death and the parents` adjustment to this situation. Furthermore, the findings are discussed from the theoretical perspective of The Dual Process Model of Coping with Bereavement and family resilience theory. Based on the findings of this study and the risk of severe psychological and relational difficulties after traumatic deaths, we recommend considering family-oriented help for DRD-bereaved families in two domains. These include, first, the family’s need and ability to adapt roles and relationships to new tasks, such as, for example, the caretaking of children. The second relates to creating a space and environment for emotional sharing and joint meaning-making processes between family members.